Recognize the presentation of a patient with one of the
different types of prostatitis, and recommend treatment
for each.

Counsel patients with prostate cancer with regard to treatmentoptions.

Recommend medication treatment for BPH, prostatitis, and
prostate cancer. Also, the pharmacist should be able to monitor
the efficacy of medication treatment and adverse effects.

Develop ways that management of prostate health and
counseling can fit into the pharmacist's practice.

The prostate is a male accessory
sex gland located below the urinary
bladder and anterior to the
rectum. This walnut-sized gland is
heart-shaped, soft, and mobile on palpation,
which is done manually
through the rectal mucosa. The gland
secretes an alkaline fluid that becomes
part of the semen during ejaculation.
The high concentration of zinc that is
found in the fluid may provide an antibacterial
effect.

Although the physiologic function
of the prostate is minimal, its impact
on the quality of life in elderly patients
can be quite profoundregardless of
whether the patient has benign prostatic
hyperplasia (BPH), prostatitis, or
prostate cancer.1-3 These disorders will
be discussed, with an emphasis on
available medication treatments and
opportunities for pharmacists to use
their unique, interventional skills for
each disease state.

Presentation of the Patientwith BPH

BPH is characterized by lower urinary
tract symptoms (LUTS) that are
bothersome and can be attributed to
either prostate tissue hyperplasia or
increased tone. Although the relationship
between BPH and LUTS is complex
and has not been completely elucidated,
BPH may result from a variety
of factors. In the adult, testosterone is
converted into dihydrotestosterone
(DHT) by the intraprostatic enzyme
5α-reductase. A growth spurt of the
prostate tends to occur between the
ages of 40 and 80, largely thought to be
due to DHT. Many men experience
prostate growth; however, in patients
who present with LUTS, this growth
spurt may result in hyperplasia of
prostate tissue around the neck of the
bladder. This is known as the static
component of BPH. The dynamic component
of BPH occurs because stimulation
of α1-adrenergic receptors within
prostate tissue leads to smooth muscle
contraction and increased tone in the
bladder neck, thus causing further
obstruction. Current medications for
this condition are targeted for relief of
its static and dynamic components.1

Static and dynamic factors together
result in the LUTS with which BPH
patients present. Symptomsincluding
hesitancy, dribbling, incomplete
emptying, weak stream, and straining
to urinateusually are obstructive in
nature on initial presentation.1 During
this phase of BPH, the prostate has
enlarged substantially so as to interfere
with bladder emptying. Prostate size is
not necessarily proportional to the
severity of LUTS, however, as symptoms
depend primarily on the amount
of urethral lumen and bladder neck
obstruction. Patients with hesitancy
may need to put pressure manually on
their bladders to initiate voiding, and
dribbling could cause the patient public
embarrassment.

As BPH progresses, urinary frequency,
urgency, and nocturia can develop.
These irritative symptoms are consequences
of long-standing bladder neck
obstruction, whereby the muscles of
the bladder neck enlarge in an attempt
to compensate for the obstruction.4
This hypertrophy results in bladder
decompensation, with a diminished
capacity to store urine. Urinary frequency
and urgency develop because
the bladder becomes hypersensitive to
the small amounts of urine that cannot
be cleared through regular voiding.
Patients may exhibit "toilet mapping,"
whereby the incessant need to urinate
induces them to accommodate voiding
into every activity of daily living.
Furthermore, nocturia awakens patients
every couple of hours throughout
the night. Some patients even
admit to keeping a bedpan or a
makeshift urinal in their bedrooms.

Eventually, untreated BPH can lead
to recurrent urinary tract infections
(UTIs) due to the inability to void completely.
Other complications include
chronic renal impairment, bladder
stones, incontinence, and hematuria.1
Thus, a patient presenting with longstanding,
untreated BPH may require
assessment for possible complications.

A patient presenting with LUTS represents
only a probable case of BPH.
Subsequent tests, such as the serum
biochemical marker prostate-specific
antigen (PSA) test and a digital rectal
examination (DRE), must be done to
rule out other causes of LUTS. Thus,
the diagnosis of BPH is made primarily
after other common causes, such as
prostatitis and prostate cancer, are
ruled out.5 For example, a current PSA
level test can help rule out a potential
diagnosis of prostate cancer. Whereas a
PSA level of <4 ng/mL is considered
normal, a level of >10 ng/mL can predict
prostate cancer about 66% of the
time. A PSA level between 4.1 ng/mL
and 10 ng/mL may indicate BPH when
other causes of LUTS are ruled out.6

The American Urological Association
Symptom Score Index (AUASI) is the
most widely used clinical assessment
instrument for LUTS from BPH (Table
1). Because alleviation of symptoms is
the main goal for patients with BPH,
treatment is aimed at decreasing these
symptom scores. The clinician records
a baseline score when the patient is
diagnosed with BPH, thus allowing
recognition of a treatment effect once
medication is started. Patients themselves
generally recognize relief or
worsening of LUTS when the AUASI
decreases or increases by 3 points,
respectively.5

In addition to improving symptoms,
the traditional goals of therapy include
attenuating disease progression and
preventing complications from either
untreated or undertreated BPH.
Because quality of life and symptom
improvement are the main goals, the
patient's concerns should take precedence
in treatment considerations. An
initial evaluation would include a
detailed history of LUTS, a past medical
history, a record of concomitant medications,
and a baseline PSA and DRE.
Next, the clinician would categorize
the patient as having mild, moderate,
or severe BPH, based on the AUASI
(from a score of 0-7, 8-19, and 20-35,
respectively). The subsequent treatment
plan would depend upon this
categorization.1 Whereas mild BPH
usually is treated with watchful waiting,
moderate BPH with bothersome
symptoms can be managed with medications.
Treatment options for severe
BPH include surgical intervention with
prostate resection or with minimally
invasive treatments including transurethral
needle ablasion, transurethral
microwave heat treatment, and interstitial
laser therapy.7

Role of Medications for Reliefof LUTS

As stated above, moderate BPH usually
is managed via medications, including
α1-receptor inhibitors and 5α-reductase inhibitors. The α1-receptor
inhibitors decrease smooth muscle tone
in the prostate tissue, urethra, and bladder
neck, thereby alleviating the
dynamic component of LUTS. Their
action of relieving LUTS is relatively
quick, compared with that of 5α-reductase
inhibitors. Thus, α-receptor blockers
are considered first-line therapy
when the patient needs significant and
rapid symptom relief.8 They do not
exert any appreciable effect on either
prostate size or PSA levels, however.

The α1-receptor inhibitors can be
stratified as first-, second-, or third-generation
agents. Stratification depends
upon several factors, including adverse
effect profile, degree of receptor selectivity,
and chronology of discovery of
each medication. Stratification is not,
however, related to efficacy since all α1-receptor blockers are equally efficacious.
Phenoxybenzamine is the sole
first-generation agent, but its nonselectivity
and severe cardiovascular adverse
effects make it an unpalatable choice
for BPH. The second-generation agents
include terazosin and doxazosin. Tamsulosin
and alfuzosin comprise the third-generation
agents.7

Terazosin and doxazosin are considered
long-acting second-generation
α1-receptor inhibitors.9 The once-daily
starting doses for these medications are
generally low (1 mg at bedtime [hs] for
each), and they are titrated by doubling
the dose every 2 weeks until
either the patient has significant relief
of LUTS or the maximum dose is
achieved (10 mg hs and 8 mg hs for terazosin
and doxazosin, respectively).
Terazosin and doxazosin inhibit both
subreceptors of α1 (α1A receptors and
α1B receptors, which are found mainly
in the prostate and the vascular epithelium,
respectively).9 Thus, the use of a
low starting dose and nighttime administration
attenuate the first-dose
effects of orthostatic hypotension,
which results from the inhibition of
α1B receptors. Other adverse side
effects include syncope, malaise, dizziness,
and somnolence.9 Prazosin,
another α1-receptor inhibitor, is not
approved by the FDA for BPH, and its
use generally is not feasible due to the
need for 3-times-daily dosing.

The third-generation α1-receptor inhibitors,
tamsulosin and alfuzosin, are
known as uroselective blockers because
of their selective action on prostate tissue
without a concomitant reduction
in blood pressure. Tamsulosin, available
as a 0.4-and a 0.8-mg/day dose,
exhibits a 10 to 12 times greater affinity
for α1A receptors, which results in
clinically insignificant orthostatic
changes and first-dose effects.10 Although
dosing is once daily, administration
at bedtime is not necessary.
Also, the onset of effect can occur within
the first week of therapy, and dose
titration usually is not needed. In fact,
clinical trials revealed that the higher
dose increased the onset of adverse
effects without increasing the degree of
symptom relief. Tamsulosin is generally
well tolerated. Its adverse effects
include rhinitis, dizziness, asthenia,
and abnormal ejaculation.10

Although alfuzosin also exerts a
selective action on prostate tissue without
reducing blood pressure, this effect
is not necessarily related to receptor
specificity. Available as a 10-mg/day
dose, it is similar to tamsulosin with
respect to the clinically insignificant
orthostatic hypotension and onset of
effect. It shares the same mild adverse
effects, with the exception of the ejaculatory
dysfunction sometimes encountered
with tamsulosin.11

The 5α-reductase inhibitors, finasteride
(5 mg daily) and dutasteride (0.5
mg daily), decrease conversion of
testosterone to DHT in the prostate.
These medications also cause apoptosis
of prostate cells, thus alleviating the
static component of BPH, eventually
shrinking the prostate tissue itself, and
relieving LUTS.12-14 Daily administration
results in symptom improvement after
an average of 6 months. Also, patients
with a significantly enlarged prostate
(≥40 g) experience the greatest symptom
improvement. Finally, patients taking
this class of medications are less
likely to have acute urinary retention or
to need surgical intervention.

Two special concerns regarding the
use of 5α-reductase inhibitors need to
be discussed. These drugs are contraindicated
in women when they are
or may potentially be pregnant,
because they can cause abnormalities
in the male fetus. Also, women who are
or may be pregnant should not handle
crushed or broken tablets due to the
potential for absorption of the medication
through skin. Only crushed tablets
are harmful, however, because a protective
coating alleviates this concern
with normal handling. Another concern
regarding finasteride is that, since
it causes an actual reduction in the size
of the prostateand prostate size is
proportional to PSApatients receiving
finasteride may lose the sensitivity
of the PSA in detecting prostate cancer.
This sensitivity is not compromised,
however, if the patient's PSA value is
multiplied by a factor of 2 when finasteride
has been taken for 6 months or
longer.15 Adverse effects most prevalent
with this class include erectile dysfunction,
ejaculatory disorders, and gynecomastia.

The most widely used phytotherapeutic
agent is Serenoa repens (saw palmetto).
Patients who present with mild
LUTS and are already taking herbal
therapy should be monitored for disease
progression. Actual studies regarding
efficacy suffer from poor study
design. Furthermore, phytotherapy
should not be used for the relief of
moderate or severe BPH because delaying
proper treatment could lead to
complications.16

Because α-receptor blockers and 5α-reductase inhibitors have different
mechanisms of action, the presumption
would be that efficacy increases
when both types are used together.
This hypothesis was confirmed in the
Medical Therapy of Prostatic Symptoms
(MTOPS) Study, the longest and
largest trial conducted to date regarding
combination therapy.17 This 5-year
study revealed that combination therapy
with doxazosin and finasteride versus
either medication alone significantly
reduced overall risk of disease
progression and improved AUASI
scores. Therefore, combination therapy
is appropriate for men with an increased
risk of disease progression or
inadequate relief of symptoms with the
maximum dose of monotherapy.

Prostatitis: Classification,Presentation, and Treatment

Prostatitis, an inflammation of the
prostate gland, is a common condition
diagnosed during 2 million physician
visits yearly and affecting approximately
10% of all adult men.18 This common
condition can range from a comparatively
simple case of acute bacterial
prostatitis to a more complex, chronic
form that is still plagued by a poor
understanding of the underlying pathophysiology
and treatment.19 Indeed,
both patients and physicians may
become frustrated with the chronic,
relapsing forms of prostatitis. Although
a clinical diagnosis of prostatitis is
based on the patient history and physical
examination, no consensus exists
with regard to the physical findings or
a diagnostic laboratory test. In 1998,
the National Institutes of Health developed
a widely used classification system,
which includes the following 4
categories: (I) acute bacterial prostatitis;
(II) chronic bacterial prostatitis; (III)
chronic prostatitis/chronic pelvic pain
syndrome (CP/CPPS); and (IV) asymptomatic
inflammatory prostatitis.2

Acute Bacterial Prostatitis(Category I)

Acute bacterial prostatitis presents
with symptoms of a UTI, including
increased urinary frequency, dysuria,
urgency, and a varying degree of bladder
outlet obstruction. Also, patients
often experience malaise, fever, and
myalgias, suggesting a more systemic
infection.

Causative uropathogens usually are
gram-negative, with the most common
one being Escherichia coli. Klebsiella,
Proteus, Enterococci, and Pseudomonas
are other species that may be
found upon culturing the urine. Initial
antibiotics are customarily prescribed
empirically, but they can be modified if
the pathogen is later found to be susceptible
to another regimen. Standard
antibiotics used for acute infections
include trimethoprim-sulfamethoxazole
(TMP-SMX), tetracycline, or a
quinolone. Although the proper duration
of therapy has not been clearly
defined, antibiotics can be continued
for 3 or 4 weeks to prevent relapse if
the patient continues to respond clinically.
Compared with the other categories,
acute bacterial prostatitis is easily
recognized and treated.

Chronic Bacterial Prostatitis(Category II)

The same organism, usually E coli,
often causes the recurrent episodes of
UTI that occur with chronic bacterial
prostatitis. Cultures of prostate-specific
specimens such as expressed prostatic
secretions (EPS) suggest that the
prostate is the focal point of infection,
although no single clinical finding is
diagnostic. The symptoms can be quite
variable, including irritative LUTS,
fever, myalgias, and pain in the back,
testes, or penis. Patients can be asymptomatic
between remitting episodes,
however, and the prostate is often normal
on DRE.

The efficacy of antibiotic treatment
depends upon penetration of the
lipophilic antibiotic into the prostatic
epithelium. Unfortunately, most of the
antibiotics that achieve highest penetration
are not effective for gram-negative
uropathogens. Therefore, failure is
thought to occur because of poor
antibiotic penetration.2 Due to the
expense of newer antibiotics and the
need for prophylactic therapy for
recurrent disease, 4-to 12-week therapy
with TMP-SMX or fluoroquinolones
is a reasonable initial choice.

While acute and chronic bacterial
prostatitis (categories I and II) are the
best understood forms, they are much
less common than CP/CPPS. This condition,
formerly called nonbacterial prostatitis,
generally is diagnosed when
chronic symptoms are accompanied by
negative midstream urine cultures. In
contrast with the other forms, CP/CPPS suffers from a limited understanding
as to the underlying etiology.
In fact, studies have suggested that the
prostate may not even be the source of
pain for this condition. Instead, pain
may result from a complex interaction
between psychological factors and dysfunction
in the neurologic, immune,
and endocrine systems.20 Therefore,
other causes of pelvic pain must be
excluded.

Traditionally, CP/CPPS has been subcategorized
into 2 subtypes, based on
whether patients have leukocytes in
their EPS (IIIA. inflammatory) or no
evidence of inflammation (IIIB. noninflammatory).
Treatment strategies for
CP/CPPS include antibiotics and α-blockers. Colonization of uropathogens
and infection in the prostate can
develop in patients with inflammatory
CPPS, and studies suggest that up to
50% of patients in this subclass
respond to antibiotic therapy when it
is given for 2 to 4 weeks.18 Data are
emerging, however, to indicate that
antibiotics are not helpful for patients
with noninflammatory CPPS.21 In this
subclass of patients, α-blockers have
been useful in pain relief when given
for an extended period of time (14-24
weeks). Medications that have been
studied include terazosin, alfuzosin,
and finasteride 5 mg daily (useful for
pain relief in one study).22-24 It is worth
noting, however, that a recent trial
comparing ciprofloxacin, tamsulosin,
both, and placebo resulted in no significant
differences in all groups studied.25

Until more research is completed
regarding CP/CPPS, patients with this
frustrating, painful form of prostatitis
may continue to experience substantial
morbidity. The following are 3 reasonable
axioms to keep in mind for the
treatment of CP/CPPS: (1) although
antibiotics have been shown to relieve
pain for patients in category IIIA, ongoing
empiric administration in patients
with long-standing CP/CPPS is not recommended19;
(2) prolonged treatment
with α-blockers appears to be necessary
to yield pain relief21; and (3) patients
with ongoing, refractory CP/CPPS may
need combination therapy, although
further studies in this area are needed.21

Asymptomatic InflammatoryProstatitis (Category IV)

Patients are placed in this category
when other urinary tract issues are
being evaluated. Infection or inflammation
of the prostate occurs in the
absence of pain. No treatment is indicated
unless the patient presents with
an elevated PSA level or unless prophylaxis
is needed prior to endoscopy or
surgery.

Considerations for thePatient with Prostate Cancer

Accounting for 11% of the cancerrelated
deaths in men, malignancy of
the prostate is the second leading cause
of cancer-related deathsecond only
to lung cancer.26 Although the overall
5-year survival rate is quite encouraging
(96%), survival rates are dependent
upon the extent of disease progression
at diagnosis. For example, the 5-year
survival rates range from approximately
100% for those with localized cancer
to 34% for those with disease metastasis.
Survival rates do decrease over
time, though, with overall survival
decreasing to 75% and 54% after 10
years and 15 years, respectively.26

Prostate cancer is a disease of the elderly.
Incidence correlates with age and
varies with race and other risk factors.
The average age of men at diagnosis is
72. Although Hispanics, Asians, and
Native Americans all have a lower incidence
of this malignancy than Caucasians,
African Americans have a
higher incidence. In addition to age
and race as primary risk factors, a family
history of a first-degree relative with
prostate cancer increases the risk.
Specifically, the risk doubles or triples if
the patient's father or brother, respectively,
has prostate cancer. Other possible
risk factors include BPH, high-fat or
low-fiber diets, or decreased consumption
of soy protein or vitamin E.27

Because the 5-year survival statistics
are relatively favorable, screening remains
controversial, based on the fact
that routine screening has not yet
decreased mortality. The American
Urological Association recommends
screening with a DRE and a PSA assessment
yearly when men reach 50 years
of age and have at least a 10-year life
expectancy. The American Cancer
Society additionally recommends that
screening should begin at age 45 for
African Americans or when 2 or more
first-degree relatives have had prostate
cancer.26

Both the DRE and the PSA concentration
are used to screen for prostate
cancer, although both are fraught with
uncertainties in detection. An enlarged,
nodular prostate could suggest
prostate cancer, but the DRE is limited
by its variability with clinician observation.
The PSA can be used to assist in
the diagnosis of prostate cancer, and it
also serves as a tool to monitor disease
progression and efficacy of treatment.
Yet, the PSA is a limited tool that is
poorly predictive of cancer unless the
PSA is >10 ng/mL (a 66% chance).
Comparatively, there is a 25% chance
of cancer when the PSA is in the "gray
area" of 4 to 10 ng/mL.26 The goal for
using the DRE and the PSA test is to target
those patients most likely to need
biopsy or expensive imaging procedures,
thus avoiding aggressive screening
and treatment of clinically insignificant
disease.

Because prostate cancer is a slowly
progressing disease, patients usually do
not exhibit symptoms until it becomes
locally advanced.27 Both obstructive
and irritative symptoms can present at
this time. Additionally, patients may
have erectile dysfunction and painful
ejaculation. Once the cancer progresses
to an advanced metastatic form, it can
spread to the abdominal and pelvic
lymph nodes and the lumbar spine.
Patients with these metastases often
complain of pain in their lower back
and pelvis. Prostate cancer also can
metastasize to the liver, lungs, and
adrenal glands.26

When the patient presents with
LUTS and positive findings with the
DRE or PSA test, a pathologist must
make a confirmation via prostate biopsy.
Cellular features and degree of differentiation
determine the grading of
the tissue sample, where tissue with
more poorly differentiated disease is
designated by a higher Gleason score.
The Gleason score is the most common
grading system and has prognostic significance
(Table 2). The 10-year survival
rates for cancer confined to the
prostate, regional extension of the cancer,
and metastases are 75%, 55%, and
15%, respectively.28

Treatment Options forProstate Cancer

The stage of the cancer can be determined
by the tumor, node, and metastasis
(TNM) system. As the name implies,
the TNM system is based on
tumor size, lymph node involvement,
and whether the disease has metastasized.
The TNM system can be used to
classify prostate cancer further into
stages I through IV, depending on
tumor size and degree of disease
spread. Thus, treatment strategies depend
upon the Gleason score, initial
stage of the disease, life expectancy,
and presence of concomitant disease
states. For example, patients would
receive aggressive treatment if they presented
with no comorbid conditions, a
low Gleason score, and a life expectancy
of >10 years. Conversely, those with
the opposite conditions (ie, a high
Gleason score, >70 years old, and a
<10-year life expectancy) would be
more likely candidates for watchful
waiting, with treatment started upon
symptom presentation.26

Viable options to treat early grades of
cancer (Gleason scores 2-5) include
radical prostatectomy and radiation
therapy. The curative option of prostatectomy
usually is reserved for men
<70 years old with a life expectancy of
>10 years and cancer that is confined
to prostate tissue.29 Complications with
this option, which are more prevalent
than with any other treatment, include
a significant risk for erectile dysfunction
andto a lesser extenturinary
incontinence.

Radiation therapy is a more frequent
option for those >70 years old, who
generally are considered poorer candidates
for surgery. Similar to prostatectomy,
it is also a curative treatment
option and is used for patients with
locally advanced disease. This option is
most effective for patients with earlystage
disease and Gleason scores of 2 to
4. Radiation also, however, can provide
palliative treatment for metastasized
cancer.26 Radiation therapy is implemented
by either external beam radiation
therapy (EBRT) or interstitial
implantation (brachytherapy). EBRT,
administered daily for 4 to 6 weeks,
involves gamma rays excising affected
prostate tissue through radiation.
Brachytherapy, a more convenient
therapy requiring only 1 outpatient
treatment, involves radioactive capsules
implanted into the prostate tissue.
Radiation therapy can cause local
inflammation, rectal irritation, LUTS,
and some erectile dysfunction.30

Because hormone therapy can yield
up to an 80% response for metastatic
cancer, it usually is incorporated in the
treatment of moderate-to-late-stage
disease. Medications can be given in
combination with radiation therapy
for advanced disease, but they also can
be initiated for localized cancer in
patients who are not candidates for
surgery or radiation. Although a variety
of choices are available in the categories
of estrogens, luteinizing hormone-releasing hormone (LHRH) agonists,
and nonsteroidal antiandrogens
(Table 3), an unfortunate fact of therapy
at this point is that the cancer
becomes refractory to hormones for
most patients within 1 to 1 1/2 years.31

The first hormonal therapy developed
in the treatment of prostate cancer,
diethylstilbesterol (DES), is no
longer available. Testosterone release
from the testes is inhibited because
gonadotropin-releasing hormone is
inhibited from the hypothalamus.
Although it is not produced commercially
due to its undesirable toxicities,
DES can be obtained as a second-line
agent from specialty compounding
pharmacies. Conjugated estrogens and
estradiol are used for chemical castration
but are limited by potentially
severe adverse effects (Table 3).31

Because LHRH agonists are as effective
as bilateral orchiectomy to decrease
testosterone levels, this class of
medications often is used as first-line
therapy.26 Leuprolide, triptorelin, and
goserelin are the available choices in
this class labeled for this indication. By
down-regulation of receptors on the
pituitary, they inhibit release of follicle-stimulating hormone and luteinizing
hormone (LH). Ultimately, the production
of testosterone is inhibited
because of the reduction of available
LH to the testes. The reduction in
testosterone levels and the tumor
response are comparable to those
achieved with bilateral orchiectomy. A
significant adverse effect known as a
"tumor flare" or "testosterone flare" is
associated with use of LHRH agonists
for the first 1 to 2 weeks. During this
time, the initial surge in testosterone
(until eventual down-regulation occurs)
can lead to tumor growth and is
characterized by hot flashes, LUTS,
lethargy, sexual dysfunction, and bone
pain.31 The effects of the initial testosterone
flare, however, can be greatly
reduced by using concurrent estrogen
or antiandrogen therapy during the
first 2 weeks.26

Nonsteroidal antiandrogens include
flutamide, bicalutamide, and nilutamide.
Because monotherapy with
these medications is less efficacious
than bilateral orchiectomy, their place
in therapy is mainly adjunctive with
LHRH agonists.32 This strategy is
known as combined androgen blockade
(CAB), and the nonsteroidal antiandrogen
generally is added to an
LHRH agonist for 2 to 4 weeks. Although
CAB is useful for advanced disease,
it is not intended for long-term
maintenance therapy.32

Finally, disease progression and
relapse should be addressed. Clinical
employment of a concept known as
maximal androgen blockade has developed.
Disease progression despite androgen
suppression is thought to occur
due to the small amount (5%-10%) of
testosterone produced by the adrenal
glands. Therefore, the nonspecific
steroidogenesis inhibitors aminoglutethimide
and ketoconazole sometimes
are usedalong with a corticosteroid
to prevent adrenal insufficiency to
block adrenal testosterone. Yet, evidence
of superior efficacy versus other
treatments has not yet materialized in
several meta-analyses.33 Because prostate
cancer eventually progresses in
almost all patients despite hormone
therapy, investigation currently is
under way to address relapse. Once
patients are not responding to hormonal
therapy anymore, antiandrogen
withdrawal sometimes is effective.
Also, systemic chemotherapy is used
when the cancer becomes androgenindependent,
and a variety of chemotherapeutic
agents are being investigated
regarding end-stage therapy.34

The Pharmacist's Role in Prostate Health

Because periodic testing of PSA and
DRE are such an integral part of diagnosing
diseases of the prostate, the prudent
pharmacist should empower
patients of requisite age by explaining
the importance of annual testing in
this areaespecially those with urinary
tract symptoms or at risk for developing
BPH, prostatitis, or prostate cancer.
Disease-specific interventions that
require pharmacist support will be discussed
presently.

As stated earlier, the overriding goal
of BPH management is enhancement of
the patient's quality of life. Therefore,
ample opportunity exists for pharmacist
intervention and management.
When considering a choice of medications,
the pharmacist is guided by the
patient's perspective. Namely, the severity
of LUTS and the need for immediate
alleviation of symptoms are addressed
at symptom onset and with regular follow-up visits. The symptom score index
provides assistance in this regard. Also,
pharmacists can counsel on behavioral
techniques, such as fluid restriction and
caffeine avoidance after the evening
meal. Diuretics should be given solely
in the morning rather than close to
bedtime. These simple changes often
lead to considerable symptom improvement.
Finally, patients can avoid other
medications that tend to exacerbate
LUTS, such as anticholinergics, sympathomimetics,
anabolic steroids, and
other steroid precursors.

Prostatitis can be a confusing landscape
of different categories with inherent
specificities in disease state management.
The pharmacist can counsel
about the disease state itself, the proper
choice of medications for each category,
and potential adverse effects.
CP/CPPS can be a particularly frustrating
disease for both the patient and the
provider. Because research on medication
therapy for this category is ongoing,
the pharmacist can provide information
when new medications become
available.

Regarding prostate cancer, pharmacists
can counsel on both prevention
and palliative care for those undergoing
treatment. Finasteride, traditionally
a treatment for BPH, has been studied
as a preventive agent for prostate
cancer. The results of a recent clinical
trial indicate that, although finasteride
is associated with attenuation of the
risk of developing prostate cancer,
those patients who are diagnosed subsequent
to finasteride prophylaxis
could present with more advanced disease.35 Pharmacists also can counsel on
a variety of issues, including adverse
effects of medications, adherence to
therapy, and palliative care. For example,
patients with advanced cancer
often not only suffer from LUTS, but
they also may have pain control issues
from local tumor-related pain andeventuallybone metastasis. Pharmacists
can guide pain management with
recommendations of a step-care plan
with nonsteroidals, combination analgesics,
and opioid analgesics. Those
receiving narcotics for pain management
should take prophylactic measures
for constipation.

The impact of all 3 disease statesBPH, prostatitis, and prostate canceron quality of life is enormous. Thus,
these issues need to be addressed
alongside the standard staples of pharmacist
intervention, disease and drug
monitoring. Furthermore, pharmacists
should be vigilant about patients'
propensity to develop anxiety and
depression. Assistance should be provided
both with initial intervention
and follow-up care, which should be
ongoing and progressive with each
step of treatment. In this manner, the
pharmacist will be able to truly provide
comprehensive care for the patient
with declining prostate health.

Justin J. Sherman, PharmD, Assistant Professor of Pharmacy Practice, University of Louisiana at Monroe, School of Pharmacy

MWC Office of Continuing Professional Education is accredited by the Accreditation Council for
Pharmacy Education as a provider of continuing pharmacy education. This program is approved for 2 contact hours (0.2 CEU) under the ACPE
universal program number of 290-000-05-014-H01. The program is available for CE credit through August 1, 2008.

CE ANSWER FORM INSTRUCTIONS

TESTING AND GRADING PROCEDURES

Each participant achieving a passing grade of 70% or higher on
any examination will receive a statement of credit giving the
number of CE credits earned. This form should be safeguarded
and may be used as documentation of credits earned.

Participants receiving a failing grade on any exam will be notified
and permitted to take 1 reexamination at no extra cost.

All answers should be recorded on the answer form attached.
For each question, decide which choice is the best answer, and
circle the letter of the response representing your choice.

Include hesitancy, dribbling, and
incomplete emptying and are typically
the first symptoms to present.

Include urinary frequency and
nocturia and are considered to be a
result of long-standing, unresolved,
obstructive symptoms.

Are considered severe only when
the prostate is considerably
enlarged.

Will ultimately lead to complications
for most patients even with
treatment.

3. A patient with BPH has a routine
prostate-specific antigen (PSA) test done.
Because he presents with lower urinary
tract symptoms (LUTS), a symptom score
index questionnaire is used. Which of
the following results would most likely
necessitate treatment of his BPH with
medications?

PSA 2 ng/mL; score of 4 on
symptom score index

PSA 6 ng/mL; score of 7 on
symptom score index

PSA 8 ng/mL; score of 12 on
symptom score index

PSA 15 ng/mL; score of 25 on
symptom score index

4. Which of the following medications
is FDA-approved as first-line therapy for
BPH when rapid relief of symptoms is
needed?

Terazosin

Finasteride

Prazosin

Tolterodine

5. Which of the following statements is
true regarding tamsulosin?

It is considered a second-generation
α1-receptor inhibitor.

It should be dosed at bedtime to
avoid orthostatic changes.

It should be dosed initially at the
lowest dose and doubled each week
until maximum effect is achieved.

It is considered a uroselective medication
because it exhibits a greater,
more selective affinity for α1A
receptors.

6. Which of the following statements is
true regarding finasteride?

This medication decreases the conversion
of dihydrotestosterone to
testosterone in the prostate tissue.

Although this medication can
decrease the size of prostate tissue,
it may take up to 6 months to have
a significant effect on symptoms.

Patients who experience the greatest
benefit from this medication
have a problem with the dynamic
component of BPH.

Female pharmacists dispensing this
medication should handle only
crushed tablets.

7. According to the results of the MTOPS
(Medical Therapy of Prostatic Symptoms)
study, a patient who has not obtained
significant relief of LUTS with a maximum
dose of a second-or third-generation
α1-receptor blocker:

Should be switched to another second-
or third-generation α1-receptor
blocker.

Should be offered surgical intervention
for prostatectomy.

Should be started on combination
therapy with a 5α-reductase
inhibitor.

Should be given a "drug-free holiday"
to enhance response when the
medication is restarted.

8. The best candidates for receiving phytotherapy
for BPH are those with:

Mild symptoms.

Moderate symptoms.

Severe symptoms.

Symptoms refractory to surgery.

9. This type of prostatitis usually is
caused by a singular type of bacterial
organism that initiates recurrent episodes
of urinary tract infections.

Acute bacterial prostatitis

Chronic bacterial prostatitis

Chronic prostatitis/chronic pelvic
pain syndrome (CP/CPPS)

Asymptomatic inflammatory prostatitis

10. In this type of prostatitis, pain may
result from a variety of psychological,
neurologic, or immunologic factors
rather than arising directly from the
prostate itself.

Acute bacterial prostatitis

Chronic bacterial prostatitis

CP/CPPS

Asymptomatic inflammatory prostatitis

11. Which of the following is a correct
statement regarding prostatitis?